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Many clinical methods for trying to detect ascites are described, some involving the requirement for a ‘third hand’ (fluid thrill), others involving drawing on the patient’s skin. To me these seem difficult or inelegant. My preferred technique is as follows: percuss from the centre of the abdomen towards the flank; if it becomes dull in the flank, keep the finger that you strike (usually the middle finger of the left hand) absolutely still on the skin, just at the point where you think ‘this is definitely dull’; ask the patient to roll away from the hand; wait 5 seconds or so; repeat percussion.

Face and neck Aside from looking carefully at the sclerae and conjunctivae for the obvious but extremely important features of jaundice and anaemia, look in the mouth for evidence of iron deficiency, namely angular cheilitis (painful cracks at the corners of the lips) and atrophic glossitis (pale, smooth tongue), also for the raw, beefy tongue of folate or B12 deficiency. Look and feel for parotid swelling, particularly common in malnourished alcoholics. Give a moments thought to whether or not there are a lot of telangiectasiae on the face: cases of hereditary haemorrhagic telangiectasiae still sometimes appear in PACES.

As soon as you seem to have finished palpating the abdomen. 23 CS_C06 12/8/10 16:06 Page 24 CLINICAL SKILLS FOR PACES: STATION 1 – ABDOMINAL SYSTEM • ‘The palms of her hands look a bit reddened, but there are no other stigmata of chronic liver disease and no metabolic flap . ’ • ‘Looking at her face and neck, the sclerae confirm that she is jaundiced and there are a few spider naevi on the cheeks, but she is not anaemic . ’ • ‘Moving on to the abdomen itself, I notice that there is a scar in the right iliac fossa that is almost certainly that of an appendicectomy, also a feint suprapubic scar that is likely to be due to gynaecological or obstetric surgery .